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International Journal of Scientific & Engineering Research, Volume 10, Issue 3, March-2019 ISSN 2229-5518
A Comparative analysis of Water, Sanitation and Hygiene Practice of Two Vulnerable Groups of Population – Marma Tribe of Bandarban and
Dhaka City Slum Dwellers, Bangladesh By
Musharrath Munir Mou
Abstract
Nation’s developmental process runs on the basis of three
different factors, which are human resource development,
economic development and also social development. All these
developments are done by – human being and some other
related factors. We all know that, “health is wealth” – which
means that when a person is healthy then he/she would be
wealthy and productive in general. Health is one of the central
factors for the development of any nation. In our daily life we
practice many things to make ourselves healthy, through
nutritious food, fresh environment, hygienic sanitation, healthy
lifestyles and other factors. Generally, these practices are
reported more by those people who know and have strong
awareness about safe WASH (Water Sanitation and Hygiene
Practice; WHO-2030 agenda has used this short form) system.
Unfortunately some groups such as slum dwellers, poor
migrants, street people, and tribal population are highly
disadvantageous in terms of above mentioned daily practices.
Considering this background, this study has chosen two
particular groups (Marma tribe population & urban slum
dwellers) who are vulnerable in terms of socio economic
development. This study has been conducted through both
qualitative and quantitative study as both are important to
analysis for descriptive study. Sample size and sample areas
have been chosen in purposive and systematic sampling way.
Total 260 households have been selected as sample, where 200
households were from urban slum area and 60 households
were from Marma tribe stays in Bandarban district. The main
intention of this study was to find out the practice system of
WASH by the study area people and how those are affecting on
their health condition. Throughout the study it has been found
that people of these two groups have knowledge about safe
WASH system but they do not have that much awareness about
the ways. In statistical analysis independent variables were their
socio economic studies, way of water usage, how they are
practicing sanitation system, and other hygienic practices.
These variables deeply depend on people’s health condition,
that’s why dependent variables were different types of water
borne and infectious diseases and also skin diseases. If people
cannot practice hygienic lifestyle they can get affected by
Diarrhea, Cholera, Dengue, Chikungunya, and other skin
diseases. Diarrhea is a very common epidemic of this country
from the early years. It spreads a lot through different types of
unhygienic practices. Now a day tension about this disease is
getting reduced because people are being more knowledgeable
about this and they know minimum level of primary treatment to
prevent this. Day by day different and new types of diseases are
coming out and spreading challenging situation among people.
People are more tensed about the new infectious diseases
which are spreading widely. One of the new diseases which
have spread out among the people of Bangladesh, especially in
urban areas, is- Chikungunya. Mainly through a type of
mosquito this disease gets spread out. People get affected with
this in a large number. Throughout the study it has been found
that people of selected areas mostly got affected with
Chikungunya rather than other diseases. In slum area this
number is higher than Marma. Comparatively Marmas are more
vulnerable with Diarrhea than Chikungunya. So, we can see that
different area people can have different types of diseases on the
basis of their lifestyle. It has been found that Marmas mostly do
not boil drinking water, that’s why they have to suffer with
Diarrhea more than Chikungunya. On the other side, slum
dwellers mostly boil drinking water but their other living
conditions are not good and hygienic in any way. Like- many
people stays in one tiny room, most of the rooms are made by
bamboo and built on the open drainage system. So, lots of
mosquitoes stays in those drains and those bite the slum
dwellers and these result huge epidemics of Chikungunya
among these people.
In national level we have found out Diarrhea is the most
common epidemic but this results vary from study area. Cholera
or Diarrhea these are age old disease. Although its incidence is
declining and new diseases such as Chikungunya or Dengue
are emerging. Moreover, this study has been conducted with
selective sample which cannot represent whole nation. Because
in national level way of practicing WASH system is different in
terms of their knowledge, their geographical condition, their
socio-economic condition, and so on. Diarrhea is observed
nationwide while Chikungunya is mostly centered on urban
areas. Basically what is true for the whole is not true for
selective areas or persons. This is call ecological fallacy.
From this study it has been found that they have knowledge
about safe WASH practice but they are not aware about their
practicing system. It happens due to lack of proper education,
lack of implementation of rules and services from government
and also lack of responsibilities of authoritative member. We
need to sort out these problems to come up from these
epidemics and help those socially vulnerable groups.
Key words – WASH (Water, Sanitation and Hygiene Practice),
Marma, Urban slum dwellers, Communicable diseases, Skin
diseases, Water borne diseases, Health service center.
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Chapter – 1 Background
1.1 Introduction
Adequate water and sanitation hygiene are most essential components
in terms of health for each and every person. Hygienic practice can
make people’s lifestyle better and healthier. Right now it is one of the
main concerns for Bangladesh because good health condition is one of
the major elements to experience socio economic development. To
increase economic growth people need to think first for human
resource development, because such development can happen if the
person can stay active and well-nourished and do hygienic practices.
Health care services from different health care centers are being
provided on every sector to prevent and also to cure the infections and
spread of diseases.
About 45 different Tribal groups are now living in Bangladesh, mostly
in the districts of Rangamati, Khagrachari, Rajshahi, Sylhet,
Bandarban, Chittagong, and Cox’s Bazaar. Adequate health care
services and knowledge regarding safe water and sanitation system
cannot reach at micro level due to insufficient attention from concerned
authorities. Consequently these tribal people are used to be affected
through many types of infectious diseases and also through water
borne diseases due to unhygienic water and sanitation practices. To
get the safe drinking water they need to go far from their houses and
those water sources are not totally safe to drink. They still use
unhygienic sanitation and even sometimes some people used to
practice open defecation. Although their overall condition is being
developed through education, health care facilities, like “Kollyani
Shastho Sheba” but still they get infected frequently.
It is not only a matter of rural and tribal areas; basically it is a common
matter for all vulnerable groups. For example, urban slum dwellers are
frequently getting affected by infections due to unhygienic practices.
These people are not using fresh drinking water and hygienic
sanitation practices due to inadequate facilities, limited knowledge and
awareness, and so on. Quality of water, sanitation system and
unhygienic practices has a significant impact on the health particularly
on children. They tend to practice all types of unhygienic activities,
which substantially affect their health. Available evidence suggests that
most of the slum dwellers are suffering with many types of infectious
and water borne diseases just because of their unsafe WASH (Water
Sanitation and Hygiene Practice; WHO-2030 agenda has used this
short form)system. This study focused on the real scenario of WASH
system of Marma communities of Bandarban district and slum dwellers
of Dhaka city. Due to contextual, cultural, behavioral and other factors,
health problems of these two groups could be different. However,
limited information are available until recently for the questions like
“how they differ in terms of health determinants mainly related to water,
sanitation and hygiene practices and how these factors are associated
with their health conditions.
1.2 Research Questions
Based on the abovementioned background, the research questions are
formulated as follows:
1. What are the differences between Marma Tribe and Dhaka
City Slum Dwellers in terms of water, sanitation and hygiene
practices?
2. How these practices are associated with their health
conditions?
1.3 Objectives
To address our research questions, this research has set both general
and specific objectives. The general objective of this research is to–
Assess the prevalence of safe WASH system among the study
population.
Additionally, following specific objectives are set:
1. To knowhow study population got affected by infectious and
water borne diseases focusing on their water, sanitation and
hygiene practices
2. To find out their level of knowledge and their awareness
about safe WASH system
3. To compare their situation with national level situation and
find out the gaps.
1.4 Hypotheses:
1. Availability/ access to safe drinking water, sanitation and
hygiene practices are likely to be inadequate as compared to
national level.
2. Prevalence of infectious diseases (Diarrhoea& Chikungunya)
will be higher who use poor drinking water, poor sanitation
and unhygienic practices.
3. Lack of awareness regarding safe WASH system makes the
study population vulnerable regarding their developmental
process.
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Chapter – 2 Literature Review
Use of safe drinking water, improved sanitation and hygiene practices
necessarily leads to improved health. Health attendants has given
clear evidence about washing hand at some important time, like- after
defecation and before having meal is mandatory for all. Hand washing
with soap can significantly reduce the incidence of Diarrhoea, which is
the second leading cause of death of ‘under five children’ throughout
the world (UNICEF, 2003). According to UNICEF, about 50 percent of
diarrhoea can be reduced just by washing hand with soap after
defecating and before having meal. Besides that it also reduces other
infectious diseases, like- pneumonia, cholera, skin diseases, and so
on.
Absence of using safe water, decent sanitation system and good
hygiene can result devastation of health and wellbeing of people.
Countries like- India, Bangladesh or any other developing countries
especially least developed countries are mostly at high risk of various
infectious diseases, like- Diarrhoea, skin diseases and water borne
diseases. Most of these are transmitted through contaminated water,
food and unhygienic practices. An estimate provided by World Health
Organization (WHO) showed that– unsafe water, sanitation and
hygiene are the leading global risks for death. These are responsible
for 1.9 million deaths in 2004. They also added that around 10% of the
total burden of disease worldwide could be prevented by improvement
of drinking water, sanitation and hygiene practices.
In Southern Africa from total under nutrition population, about half of
under nutrition is associated with inadequate water, sanitation and
hygiene practices, because diarrhoeal diseases and parasites prevent
people from absorbing nutrients from food. This under nutrition can
make people stunted and wasted which results imbalanced body mass
index (BMI) (Water Aid, 2016).
Figure 1: Prevalence of underweight, stunting and wasting in Bangladesh during 2004 to 2013
Source:Iffat Mahmud and Nkosinathi Mbuya, The World Bank study, 2016.
More than 1 in 3 young children in Bangladesh suffer from various
illnesses including physical, mental and cognitive developmental
delays because of poor nutrition (NIPORT, 2016). Poor nutritional
status of mother is the main cause of child’s poor nutrition. In other
words, if mother cannot have proper food and nutrition then her child
will also suffer from poor nutrition.
Figure 1 presents the trend of under nutrition statuses of ‘under five
children’ in Bangladesh for the period of 2004 to 2013. Nutritional
experts say that lack of accessibility and availability of safe drinking
water, good sanitation and hygienic practices are the leading cause of
these outcomes (World Bank Group, 2016).
Water borne and infectious diseases are not only causing bad
conditions of health but also limiting human resource development.
People generally lost their abilities to be productive and cannot
participate in socio economic development due to these problems.
These infectious diseases even keep children absent to attend school
and adult to join their work which results shortage of future potential
and reduction of income. To the end we can say that limited access to
pure drinking water, good sanitation and poor hygiene practice
substantially undermine country’s economic growth and development.
43
51
15
41 43
17
36 4
1
16
35 3
9
18
U N D E R W E I G H T S T U N T I N G W A S T I N G
CHILDREN UNDERNUTRITION TRENDS IN BANGLADESH, 2013 (%)
2004 2007 2011 2013
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Table 1: Trends of life expectancy at birth, per capita GNI and HDI in Bangladesh, 1980 - 2012
Year Life expectancy at birth GNI per capita HDI value
1980 55.2 .649 .312
1985 56.9 .715 .333
1990 59.5 .762 .361
1995 62.1 .860 .397
2000 64.7 1.003 .433
2005 66.9 1.220 .472
2010 68.6 1.631 .508
2011 68.9 1.701 .511
2012 69.2 1.785 .515
Source: Bangladesh’s HDI trends (UNDP, 2013)
From Table 1 we can easily infer positive relationships between three
indicators at the national level. The more life expectancy at birth got
improved in Bangladesh the more Gross National Income (GNI) got
increased. Generally life expectancy at birth is an outcome which
depends on various factors. Some of these factors are e.g. modern
healthcare services, hygienic practices and availability of safe drinking
water. Human development index (HDI) also plays an important role in
increasing life expectancy. According to the study of Khan et al (2011),
the development in socio-economic and health sectors at the national
level does not necessarily mean that all segments of the society are
equally benefitted. Some groups (e.g., rich, elite) are getting more
advantages than others (e.g., poor). So, group-specific analyses are
sometimes imperative. From this justification, this research has been
designed to check actual performance of water, sanitation and hygiene
practices among Marma tribe in Chittagong division and urban slum
dwellers in Dhaka.
Improving global access to safe drinking water and safe sanitation is
one of the least expensive and most effective means to improve public
health and save lives. The U.S. and Central Europe, where water and
sanitation services are nearly universal, significantly reduced water-,
sanitation-and hygiene-related diseases in the 20th century by
protecting water sources and installing sewage systems. However, in
developing countries, water and sanitation services are still severely
lacking. As a result, millions of people suffer from preventable illnesses
such as- Diarrhoea, Cholera, Chikungunya, and die every year.
Although the percentage of death caused by Diarrhoea has dropped by
5.5% during the period of 2001 to 2016, still many under-five children
got affected and even hospitalized (Dhaka Tribune, 2017).
Many obstacles must be overcome to improve these statistics.
Approximately 3 in 10 people worldwide or 2.1 billion, lack access to
safe and readily available water at home, and 6 in 10, or 4.5 billion,
lack safely managed sanitation (WHO, 2017). The Joint Monitoring
Programme (JMP) report on “Progress on drinking water, sanitation
and hygiene: 2017 Update and Sustainable Development Goal
Baselines” presents the first global assessment of “safely managed”
drinking water and sanitation services (UNICEF, 2017). The overriding
conclusion is that too many people still lack access, particularly in rural
areas. Bangladesh had made significant progress in improving the
health of its population, and was one of the few developing countries
that were on track to achieve Millennium Development Goals (MDGs)
4 and 5. On top of the progress, in 1990 the infant mortality rate was
100 deaths per 1000 live births and by 2006 it had declined to 52
deaths per 1000 live births. By 2016 the infant mortality rate further
declined to 28.2 % (World Bank, 2016). At the global level, the WASH
Poverty Diagnostic Initiative recommended three ways to ensure safe
and sustainable water and sanitation for all, those are (i) coordinated
investments and interventions, (ii) allocation of future investments in
proper way, and (iii) governments need to understand the gap between
policies and interventions (The World Bank, 2015).
The overall situation of Bangladesh has improved in terms of both
sanitation and water, but low levels of sanitation and arsenic
contamination in ground water remain important public-health threats.
As of 2003, according to the government, some 42 percent of
Bangladeshis does defecation themselves along roadsides, behind
bushes, aside homes or wherever they could find a place to go (Anas,
2017). Since open defecation is linked to transmission of many
diseases, such as Cholera, Diarrhoea and Dysentery, still, the quality
of sanitation coverage is an important public health issue. Latrines
situated mostly in remote areas are still classified as “unimproved.”
Drinking water access is widespread, but half of the drinking water
consumed fails to meet water safety standards. In urban areas of
Bangladesh, piped water supply reaches only about one-third of the
population, and there is no systematic sewer disposal and treatment
system. Only Dhaka, Bangladesh’s capital city has a sewerage
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system, and it has served only around 18 percent of the city (World
Bank, 2016).
Convincing people to defecate in a fixed place is a first step in
sanitation improvements. UNICEF Bangladesh has involved in the
largest intensive hygiene, sanitation and fresh water improvement
project ever attempted in a developing country. The Bangladesh Rural
Water Supply and Sanitation Project, to which the World Bank has
committed $43 million since 2012, aims to increase a safe water
supply and hygienic sanitation in the rural areas of Bangladesh, where
shallow aquifers were highly contaminated by arsenic and other
pollutants. The Sanitation, Hygiene Education and Water Supply in
Bangladesh (SHEWA-B) project aimed to reach 30 million people in
five years (2007- 2011). Low rates of progress in improving water
supply coverage reflect the prevailing situation of arsenic
contamination of shallow tube-wells (F. Ahmed & T. Ahmed, 2014).
Health care associated infections affect hundreds of millions of patients
every year, with 15% of patients estimated to develop one or more
infections during a hospital stay (Allegranziet al., 2011). Mostly women
and children get affected due to this reason, like every day many
children died from preventable diseases, like- Diarrhoea, and Cholera.
On the other hand, according to UNICEF (WASH) worldwide 2.5 billion
people lack access to improved sanitation; 748 million people lack
access to an improved source of drinking water and about 1 billion
people practiced open defection. According to daily newspaper (The
Independent, 2014-2015), reported that - due to unhygienic practice
about 37% children got affected with skin diseases, 32% from fever,
and 22% from diarrhoea.
Many other infectious diseases are also spreading with a concerning
number. Rather than Diarrhoeal disease some new diseases like,
Chikungunya become an epidemic. People are being widely affected
with such diseases like, Chikungunya or Dengue. People’s lack of
awareness and their life style lead them into these tensions. From April
1, 2017, to Sept 7, 2017, the Bangladeshi Ministry of Health reported
that about 984 cases confirmed by real-time PCR assay and more than
13,176 clinically confirmed cases of Chikungunya patient in 17 of 64
districts (Kabir et al, 2017). Mainly this disease has outbreak in two
continents which are Asia and Africa. In 2016 there was a total of
349,936 suspected and 146,914 laboratory confirmed cases of
Chikungunya in these continents (WHO, 2017).
Sanitation and hygiene are critical to good health survival and
development. Many countries are still challenged in providing adequate
sanitation for their entire population. People of some areas are still at
risk to water, sanitation and hygiene (WASH) - related diseases. In
these areas absence of basic sanitation and modern latrine system
polluting the environment and also creating risk factor for the society.
Due to open defecation, open disposal of human wastages, water, land
area also get polluted. According to United Nation’s Millennium
Development Goals Report in Bangladesh one in five girls of primary
school are not able to attend school during their menstrual period, as
they don’t get proper sanitation support, hygienic practice and lack of
fresh sanitary napkins. The installation of toilets and latrines may
enable school children especially menstruating girls continue higher
studies by avoiding the barriers. On the other hand in many areas
there is water scarcity. In that case mostly female members of the
household have to go far to collect water. So, they need to spend huge
time to collect water (UN Water, “Gender, Water and Sanitation”, 2005-
2015).
In many areas of Bangladesh, particularly those in hard to reach areas,
people lack access to improved and sustainable water and sanitation
facilities due to challenging environmental conditions, complex social
factors and a lack of knowledge of the importance of using improved
water and sanitation facilities. As a result, many people do not practice
key hygiene behaviors including the practice of effective hand washing
with soap at key times, as well drinking arsenic-safe water and using
improved latrines (Dreibelbis et al, 2015).
Although Bangladesh has developed significantly with regard to access
improved water and sanitation facilities over the last few years, there
are pockets of areas that have received very little attention due to
geophysical, socio-cultural and economic situation. With very little
infrastructural development, road communication network in particular,
water and sanitation coverage in these areas still remain much below
from the minimum level. Extreme poverty in these hard to reach areas
exacerbates the water and sanitation crisis. Government of
Bangladesh had set its targets of achieving full coverage of water and
sanitation by 2011 and 2013 respectively; these areas need special
attention in different aspects of development including technological
options, social mobilization, financial resources, and service delivery
mechanism because of special geographical, hydro-geological and
social setting (NIPORT, 2011). It needs to be verifying again on recent
perspective and find out the left lacking, because still there are some
vulnerable areas which are not getting access of these facilities. Areas
like slum or hilly area are mostly getting eliminated while implementing
these plans.
On the basis of needs people started to switch their occupations.
Mostly people started to move from agricultural sector to industrial
sector. People got migrate from rural to urban areas to seek better life
and better employment. Huge number of in-migration between rural to
urban have caused huge increase of urban slum areas. Poor people,
who come from their villages, generally tend to stay in slums with low
cost housing. Though they migrated to city for better life, in many
instances they became vulnerable more than before. Their household
conditions, environment, and sanitation are not hygienic at all. Their
houses are mostly made of bamboos, which are not hygiene to live.
Most of these houses are also located in low lands or near the
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drainage system where lots of mosquitoes roam around. Many
households together have to share toilet. Generally improved toilet
facility is treated as a good indicator for hygienic environment for slum
dwellers. Around 42.2% of the slum dwellers use pit latrine, 26.3% use
sanitary latrine, 21.1% use tin-built latrine, 8.7% use katcha latrine and
1.9% use open space (BBS, 2014). Good hygienic and sanitation
knowledge and the practices are significantly lower among the slum
dwellers than non-slum dwellers. Some of the criteria used by the
Bangladesh Bureau of Statistics (BBS) to define slums are
predominantly poor housing, poor quality or no sewerage and
drainage, inadequate drinking water supplies, insufficient or no street
lighting, and few or no paved streets or paths. In addition, many slums
covered by the BBS study were located near polluted water bodies,
swamps or putrid drainage canals. Fresh drinking water, hygiene
practices and proper sanitation systems should be accessible to slum
dwellers because these factors are related with human right.
Image 1: Typical living condition of Aftabnagar, Rampura area slum
Source: Author of this paper.
The above image of a slum area can show an overview of their WASH
practice system. Their houses are located in the area heavily affected
by stagnant water, poor drainage and household garbage. Due to their
unhygienic lifestyle automatically these people are at high risk of
having bad health conditions including water borne diseases.
The review leads us to say that human health and wellbeing are
strongly affected by the environment in which we live. Access to water,
sanitation and hygiene in everyday life is very important factor
influencing good health. Fresh water and proper hygienic sanitation
system can lead to good health; can reduce illness and water and
environmental related deaths. Improved health system is
interconnected with many factors, like- poverty reduction, higher
literacy rate, socio economic development and improved quality of
lifestyle. So, getting access of fresh water and proper sanitation
system is not just related to good health, but also related to national
prosperity. If people cannot have fresh drinking water and also cannot
use clean and safe water for daily purposes, then they would
experience lots of water borne and infectious diseases which can
affect their health, workability, personal income and productivity. Very
briefly, usage of safe drinking water, developed sanitation and hygienic
practices are really needed not only to maintain good health but also
for socioeconomic and national development.
Considering the above-mentioned background, two different study
areas namely urban slums from Dhaka city and Marma communities
from Bandarban district are selected. Selected slums varied by number
of populations. Bandarban district is mostly hilly and is not much
developed like another hilly district called Rangamati. The people of
Bandarban are slightly behind in terms of their knowledge and
awareness about different health issues. The overall health care
services are also not developed. The poverty rate of Rangamati is
about 64%, which is about 74% in Bandarban (CHTDF, UNDP, 2014).
Environmental conditions are relatively better in hilly districts. So,
Marma tribe communities live in a fresh environment as there is no
sound pollution or any kind of traffic jam, contaminated carbon-di-
oxide, and so on. Though their environment is fresh and peace also
but in terms of safe WASH practice system they are not much aware.
Lack of awareness leads them to different types of water borne
diseases, especially Diarrhoea. On the other side urban city area is
fully overloaded with huge number of population. From this huge
number a large proportion lives in slum area which doesn’t have a
fresh environment at all. As here number of population is larger than its
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land so many people have to stay in one tiny area. Their socio-
economic condition also bound them to live in a very unhygienic place.
Their living condition and the way they leads their life that causes
different types of infectious diseases. One of the leading infectious
disease with which they have to suffer most is ‘Chikungunya’. This
disease caused by mosquito and we know that mosquitoes mostly stay
in unhygienic place, polluted water and environment also. Throughout
the study it has been shown that how urban slum dwellers and Marma
tribe are leading their life regarding water, sanitation and hygiene
practices and how their way of living affects their health condition. It
needs to know what the epidemical situation of them is.
Chapter – 3
Methodology
3.1 Conceptual Framework
This study mainly analyzed water, sanitation and hygiene practices of
two vulnerable groups (urban slum dwellers and Marma Tribe) and
compared them with national level statistics. Generally, health
outcomes (dependent variables) are associated with various factors
including water sanitation and hygiene-related variables. In order to
ease our understanding, the following conceptual framework is
proposed. According to this framework, water borne and other
infectious diseases (considered as dependent variables) are
associated with various socio demographic, lifestyles, healthcare
factors including other community (e.g. crowding) or environmental
(e.g. waste management, drainage) or city (e.g. recreational facility)
level characteristics. In our study, most of these variables have been
measured categorically.
Figure: Conceptual framework to show associations between health outcomes (dependent variables) and other factors (considered as independent
variables)
3.2 Study Design
This study has been conducted using both qualitative and quantitative
methods. In research study both these studies was needed to get a
clear and analytical idea. Qualitative research has been done based on
fewer criteria by using a tool which is a tape recorder. After asking
some questions, people have discussed about their idea, practice
system and how they want to see these things. These discussions has
accomplished through group of people. It involves more interactions
between researcher and study subjects and provides more
opportunities to clarify questions like why and how. In contrast,
quantitative research is used to generate statistics based on survey
research using tools like pre-tested questionnaires. Through statistical
study quantitative method has been used to get a comparative idea
between their WASH practice system and their health condition.
3.3 Study Area
This study has been conducted on two vulnerable groups of people.
One group represents Marma tribe community of Bandarban district.
The second group of population represents slum dwellers, which were
Health Outcomes (Water
borne and other infectious
diseases) of the vulnerable
populations
Community/environmental/city/macro level characteristics
Lifestyles in terms of
their WASH practice
Healthcare facilities in
study areas
Sociodemographic factors
Age
Sex
Education
Economic status
Employment
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selected from different slums (namely Badda, Mirpur, Uttarkhan) of
Dhaka city.
A total of 60 households from five different para (Khamadom para,
Jamchori para, Girisheva para, Rajbila, KachingMarma para,
Roangchori para) were selected for Marma tribe, whereas it was 200
households for slum group. Sample sizes varied between two areas
due to difference of total number of population in two areas. According
to BBS (2014) more than 2 million slum dwellers lives in Dhaka city
slums whereas total number of Marma tribe lives in the whole country
is only 0.35 million. So, number of Marma tribe in Bandarban area
must be lesser than 0.35 million which is much lesser than total
number of slum dwellers in Dhaka city. To represent this large number
of slum dwellers, sample size of slum dwellers is larger than Marma
tribe. On the other side, in Bandarban area most of the paras consists
only 10 to 20 households whereas in Dhaka city slums consists 100 to
1000 households. That’s why number of para is more than number of
slum. The main respondent was the head of the household. Except
some questions most of the questions had been asked to head of the
household. Only some particular questions had been set for every
member of the household.
3.4 Sampling Techniques
While collecting data a particular technique has been followed that is
purposive sampling. The area of slums and paras has been chosen
purposefully on the basis of conveniency and accessibility. On the
other hand household of respondent has been chosen on the basis of
systematic sampling where every other a particular number of
household has been selected. From three slums, Mirpur (Rupali Real
estate) slum has 1000 household, so sample has been chosen from
every after 10 household, and Uttarkhan slum has about 400
households, so sample has been chosen every after 5 household and
lastly Rampura slum has about 60 households so here sample has
been chosen every after second household. On the other hand in
Bandarban area mostly paras have only 20 households. So, sample
household has been chosen in systematic way which is like every after
second household. So, in that way each para consist 10 sample
household. Paras which have 30 households there sample has been
chosen every after third household. This study has also followed
multiphase sampling analysis as some questions from the
questionnaire were for every household member and rest of the
questions has been asked only to the head of the household who was
the main respondent of this thesis.
3.5 Tools for Data Collection
Data has been collected by face to face interview with help of
structured questionnaire. The questionnaire was pre-tested and then
modified accordingly. This questionnaire mainly included those
questions which were thought important and relevant for the topic. In
the following section, information about variables (types, brief
descriptions) is given.
3.6 Description of Questionnaire
Variables
Independent Variables Dependent Variables
Socio-demographic factors Water borne diseases and other infectious diseases.
Healthcare facilities
Lifestyles related to WASH practice (water, sanitation, hygiene)
Socio Demographic Factors
This study has been conducted on particular group of people and the
main purpose of this study was to know causes and consequences of
their health situation and also to know the effect of various lifestyle
related factors (social, economic) on their health condition. As
independent variables -some socio demographic factors, healthcare
facilities, and lifestyle related WASH practices have been chosen to
analysis. Factors are— sex, education, occupation, expenditure,
WASH practice system, health care services, and so on.
Sex- This study can find out which group is more vulnerable in terms of
their WASH practice. Through frequency of sex analysis and their
other practices we have to come to know that women are more likely to
practice unhygienic WASH practices than men. So, now more attention
needs to give on female group.
Education-Education is a great factor to gather any knowledge about
hygienic practices. In this study most of the respondents were illiterate
and from them most of them do not do hygienic practice.
Occupation- Throughout the study it has been found that those who
have higher level job, like- army or teacher they are well known and
aware about hygiene practices. Even they are in less number affected
people by infectious diseases than people who are farmer or maid.
Expenditure- It needs to know how much every family needs to spend
for monthly household expenses. Marma people have to spend more
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than slum dwellers every month. Marma people have to spend a
particular portion of their income on their children’s education which
slum dwellers do not do. This practice has put effect on their life also.
After visiting field it has been understood that Marma lead
comparatively a standard life than slum dwellers.
Pattern of practicing hygiene water and sanitation system:
Water usage system- Water usage system has been analyzed as
independent variable. Through the pattern we can come to know why
or whether they are having any water borne diseases or not.
Sanitation system- Sanitation system is a very important factor which
needs to be analyzed as independent variable. What type of sanitary
latrine they are using; where they are disposing their stools and other
garbage- these can give an idea about their sanitation practice system.
Hygienic practice- Most of the people know about importance of
hygiene but they don’t know about the process of practicing it. Lacking
of proper knowledge and awareness can result many types of
infectious diseases.
Infectious and water borne diseases:
Diarrhoea- Diarrhoea is loose, watery stools. If anyone has loose
stools three or more times in one day then it can call as diarrhoea.
Acute diarrhoea is diarrhoea that lasts a short time. Chronic diarrhoea
is diarrhoea that lasts at least four weeks.
Cholera-Cholera is also a type of loose motion like Diarrhoea. It is an
infectious and often fatal bacterial disease of the small intestine,
typically contracted from infected water supplies and causing severe
vomiting.
Typhoid-It is an infectious bacterial fever with an eruption of red spots
on the chest and abdomen and severe intestinal irritation.
Dengue- Dengue is a debilitating viral disease of the tropics,
transmitted by mosquitoes, and causing sudden fever and acute pains
in the joints.
Chikungunya- Chikungunya is also a viral disease resembling
dengue, transmitted by mosquitoes and endemic in East Africa and
parts of Asia. Throughout the study this diseases has largest number
of response.
Skin diseases-Different types of skin rashes and fungus can affect
people if they do not use safe and hygienic water.
3.7 Methods and Data Analysis
As both qualitative and quantitative study has been done so for
quantitative study different statistical analysis has been conducted by
using SPSS software. For basic descriptive statistics frequency
analysis has been carried out. To ensure the relationship between
various dependent and independent variables bivariate-chi-square test
analysis has been conducted. Different analysis can give different
result. That’s why to come up with solid evidence and to know actual
relationship finally multivariable logistic regression analysis has been
done. Through multivariable analysis we needs to know whether
independent and dependent variables are significant and
interconnected or not.
Data analyses have been conducted following the nature of the data
on the basis of different methods. As here qualitative study also has
been followed so, it needs to be descriptive - case study by using
different source. Data has been collected through primary source that’s
why questions have been asked to the respondents’ naturalistic
observation and also in-depth interview by using tape recorder.
Qualitative data has been analyzed through descriptive case study.
By using MS Excel software some graph has been constructed in this
study.
3.8 Ethical Issues
In order to maintain the ethical issues, the researcher performed
several activities. Some of them are given below:
Before collection of data, approved letter of thesis has been
taken from Social Relations Department of East West
University.
Before interview, each respondent had been informed
thoroughly about the study aspects, purposes, duration of
interview and data collection methods.
Confidentiality of data and privacy of the respondents has
been maintained strictly.
Each respondent was informed that participation in the survey
was voluntary and there was no penalty for termination during
interview.
They had the option to skip question(s) from the
questionnaire.
Although written informed consent was available in the questionnaire,
the researcher pointed all these points verbally to get verbal consent.
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Chapter - 4
Results
The results of the study are presented into various sub-sections. First
simple analysis was performed to describe socio-demographic and
WASH practices for the respondents and total household members
through frequency. Then bivariable (cross-table) and multivariable
analyses (e.g. multivariable logistic regression analysis) are performed
to present major findings of the study.
Socio-demographic conditions
The socio-demographic information, based on respondents and total
household members, are presented in Table 1. Most of the
respondents were male in urban slums (64.0%) and female (53.0%) in
Marma tribe communities. Very few households had a small family size
ranging from two to seven. On an average every family had at least
four members.
Table 1: Socio-demographic information of the respondents (N = 260) and total household members* (N = 888), Slum= 200, Marma= 60
Variables Total Slum Marma
n % n % n %
Average size of House hold member 4 3.7 4.7
Age: (N*)
0-15 15-40 40-65
65+
243 404 214
27
27.4 45.5 24.0
3.1
171 307 147
15
26.7 48.0 23.0
2.3
72 97 67
12
29.0 39.0 27.2
4.8
Sex: ((N) Male
Female Transgender
156
101 3
60.0
38.8 1.2
128
69 3
64.0
34.5 1.5
28
32 0
46.7
53.3 0.0
Education: ( N) No Education Primary
Secondary Tertiary
155 58
47 0
59.6 22.3
18.1 0.0
114 46
40 0
57.0 23.0
20.0 0.0
41 12
7 0
68.0 20.3
11.7 0.0
Occupation (N):
Business Day laborer Driver
Farmer Housewife Job
Jum farming Shop keeper Garment worker
Maid Rickshaw puller Watchman
19 24 2
21 5 4
10 25 47
59 42 2
7.3 9.2 0.8
8.1 1.9 1.5
3.8 9.6 18.1
22.7 16.2 0.8
16 14 2
0 0 0
0 18 47
59 42 2
8.0 7.0
1.00
0.0 0.0 0.0
0.0 9.0
23.5
29.5 21.0 1.0
3 10 0
21 5 4
10 7 0
0 0 0
5.0 16.7 0.0
35.0 8.3 6.7
16.7 11.6 0.0
0.0 0.0 0.0
Total cost per month (N*): TK. 1000-2000
TK. 2000-5000 TK. 5000-8000 Tk. 8000-12000
Tk. 12000-15000 TK. 15000+
3
164 35 34
24 0
1.2
63.0 13.5 13.1
9.2 0.0
3
164 24 9
0 0
1.5
82.0 12.0 4.5
0.0 0.0
0
0 11 25
24 0
0.0
0.0 18.3 41.7
40.0 0.0
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This table shows that in both communities the majority group of
household members belongs to the middle age group of 15-40 years.
Most of the respondents (N=260) were illiterate in both areas (slum
57% and Marma 68%). The three leading occupations were maid
servant (29.5%), rickshaw puller (21%) and garment worker (23.5%) in
slum areas and farmer (35.0%), day laborer (16.7%) and shop keeper
(11.7%) in Marma community.
Figure 2: Level of education for all household members (N*=888)
From the above graph we can see from total household member
(N=888), about 24% Marmas are educated till primary level, whereas
slum dwellers are 20% educated till primary level. In tertiary level from
total tribal at least 2% are educated till tertiary level but any slum
dwellers are not educated till tertiary level.
Sources and usages of water
Figure 3: Percentage of drinking water purification in both areas
No education Primary Secondary Tertiary
Total 55.0% 21.0% 20.7% 0.6%
Slum 59.4% 20.0% 19.0% 0.0%
Marma 44.4% 24.0% 25.4% 2.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Level of Education of all household member
Yes No
Total 68.8% 31.2%
Slum 88.5% 11.5%
Marma 3.3% 96.7%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Whether do anything to purify drinking water
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Table 2: Descriptive analysis of water sources and usages process in slum areas= 200 and Marma community= 60 (N=260)
Variables Total Slum Marma
n % n % n %
Waysto purify drinking water (Those who purify water):
Boiling Medicine Purifier
96 2 81
53.6 1.1
45.3
95 2 80
53.7 1.1
45.2
1 1 0
50 50 0.0
Source of drinking water:
Piped water outside dwelling Tube well water Surface water
Pond/Lakes/Tank River
212 21 0
20 7
81.5 8.1 0.0
7.7 2.7
200 0 0
0 0
100.0 0.0 0.0
0.0 0.0
12 21 0
20 7
20.0 35.0 0.0
33.3 11.7
Source of water for cooking:
Piped water outside dwelling Tube well water
Surface water Pond/Lakes/Tank River
204 16
2 25 13
78.5 6.0
0.8 9.7 5.0
200 0
0 0 0
100 0.0
0.0 0.0 0.0
4 16
2 25 13
6.7
26.7
3.2 41.7 21.7
Source of water for washing clothes:
Piped water outside dwelling Tube well water Surface water
Pond/Lakes/Tank River
204 1 7
25 23
78.5 0.4 2.7
9.6 8.8
200 0 0
0 0
100 0.0 0.0
0.0 0.0
4 1 7
25 23
6.8 1.8
11.7
41.7 38.0
Source of water for cleaning utensils:
Piped water outside dwelling Tube well water
Surface water Pond/Lakes/Tank River
205 17
2 24 12
78.8 6.5
0.8 9.3 4.6
200 0
0 0 0
100 0.0
0.0 0.0 0.0
5 17
2 24 12
8.0
28.0
4.0 40.0 20.0
According to graph 2, drinking water purification was 88.5% in slum
areas, which was only 3% in Marma community. Similarly according to
Table 2, the two major ways of drinking water purification were boiling
(53.7%) and used purifier machine (45.2%) in slum areas and in
Marma areas only 2 respondents replied that they purify water in two
ways which are boiling and through medicine. In terms of water usage
system slum dwellers do all their work with piped/supply water (100%)
whereas Marmas use different sources (Drinking water from tube well
water=35%, cooking from tube well water=26.7%, washing clothe from
pond/lake/tank=41.7%, cleaning utensils from pond/lakes/tank=40%).
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Sanitation Practice System
Table 3: Descriptive analysis of Sanitation Practice System (N=260) (Slum= 200, Marma=60)
Variables Total Slum Marma
n % n % n %
Whether share toilet: Yes
No
216 44
83.0 17
194 6
97.0 3.0
22 38
37.0 63.3
If yes, no. of households who used one sanitary:
7 8 9
10 15 20
30
2 4
2 4
180
21 3
0.9 1.9
0.9 1.9 83.3
9.7 1.4
0 0
0 0
174
20 0
0.0 0.0
0.0 0.0 89.7
10.3 0.0
2 4
2 4 6
1 3
9.1
18.2
9.1 18.2 27.3
4.5 13.6
Types of toilet:
Septic tank/ Modern
toilet
Pit toilet/latrine Sealed/slap latrine Open latrine
Hanging Latrine Other
6
1
215
8 29 1
2.3
.4
82.7
3.1 11.2 .3
6
0
194
0 0 0
3.0
0.0 97.0
0.0 0.0 0.0
0
1 21
8 29 1
0.0
1.7
35.0
13.3 48.3 1.7
Disposal of child’s stool defecation:
Open place Nearby river/pond Below tree
Dustbin Other place
46 200
1
6 7
17.7 76.9 0.4
2.3 2.7
0 194
0
6 0
0.0 97.0 0.0
3.0 0.0
46 6 1
0 7
76.7 10.0 1.7
0.0 11.6
Disposal of regular garbage: Open place
Nearby river/pond Below tree Dustbin
Other place
48
197 1 7
7
18.5
75.8 0.4 2.7
2.8
1
192 0 7
0
0.5
96.0 0.0 3.5
0.0
47
5 1 0
7
78.3
8.3 1.7 0.0
11.7
Through the above data we can see that most of the households share
one toilet (83%) and about 17% household do not share their toilet with
other households. This practice is mostly common in slum area,
because about 97% household in slum area share toilet with other
households whereas 36.7% Marmas share one toilet with other
households. The major number of sharing household is 15 (83.3%).
Slum area people mostly use sealed/slap latrine (97%) but most of the
Marmas use open latrine (48%). Practice of dispose regular garbage is
also different between two areas. Slum dwellers mostly dispose their
regular garbage at nearby river/pond (96%) but Marma tribes dispose
their regular garbage at open place (78%).
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Figure 4: Dispose of stool after defecation.
From the above graph we can see that most of the Marmas dispose
their stools whether at open place (85%) or nearby river or pond
(8.3%). On the other side slum area people dispose defecation at
nearby river/pond (97%) and dustbin (3%), some dispose below tree
and other places. It can show that Marma people mostly dispose their
stools at open place and slum dwellers dispose in nearby river or pond.
Hygienic Practice system
To get the actual result it needs to know how much they are doing
hygienic practice in their daily life. Descriptive analysis has been run
on whether they wash hand after defecation or before meal. They have
been asked about using of methods while having menstruation,
because it is a very important hygienic issue for girls.
Table 4: Descriptive analysis of Hygienic Practice system (N=260) (Slum=200, Marma=60)
Variables Total Slum Marma
n % n % n %
Frequency of washing hand after
defecation: Yes No
257
3
99
1.0%
198
2
99.0 1.0
59 1
98.3 1.7
If Yes, With soap Without soap
225 32
87.5 12.5
192
6
97 3.0
33 26
56 44
Frequency of washing hand before having meal:
Yes No
248 12
95.4 4.6
193 7
96.5 3.5
55 5
91.7 8.3
If Yes, With soap Without soap
18
231
7 93
2
191
1 99
16 40
27.3 72.7
Frequency of washing food before cook:
Yes No
244 16
93.8 6.2
196 4
98.0 2.0
48 12
80.0 20.0
Study is showing that in both areas about 99% people wash hand after
defecation but from them about 87% use soap. In slum area about
97% people and in Marma community about 56% people use soap
while washing hand. So, 44% Marma tribe does not use soap after
defecation. In terms of washing hand before having meal – study is
showing that about 99% slum dwellers do not use soap and about
72.7% Marma tribes do not use soap.
Open place Nearby river/pond Dustbin
Total 19.6% 76.5% 2.0%
Slum 0.0% 97.0% 3.0%
Marma 85.0% 8.3% 0.0%
Disposal of stool after defecation
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Figure 5: Use of methods during menstruation
Above graph showing that 16.5% slum dwellers use sanitary napkin,
4.5% use cotton and about 77.5% use clothe while having
menstruation. On the other hand, about 16.5% Marmas use sanitary
napkin, 4.5% use cotton and about 77.5% use clothe and few female
members use other method rather than sanitary napkin, clothe or
cotton.
Affected diseases relates with WASH system
Table 5: Whether suffer from any water borne/skin diseases since last one year (N=260) (Slum=200, Marma=60)
Variables Total Slum Marma
n % n % n %
Yes
No
194
66
74.6
25.4
166
34
83
17
28
32
46.7
53.3
Table 6: Frequency of diseases by which people got affected in last one year (N=260) (Slum=200, Marma=60)
Variables Total Slum Marma
n % n % n %
Types of diseases:
Diarrhoea Cholera Typhoid
Dengue Chikungunya Skin Diseases
15 2 7
29 62 5
7.7 1.0 3.6
15 32 2.6
6 2 7
26 58 1
3.6 1.2 4.2
15.7 35 0.6
9 0 0
3 4 4
32.1 0.0 0.0
10.7 14.3 14.3
About 75% people got affected by water borne diseases or skin
diseases. Through the above data it has been seen that about 83%
slum dwellers and 46.7% Marmas got affected with water borne
diseases. People who got affected Slum dwellers got affected with new
upbringing disease which is ‘Chikungunya’ (35 %). On the other side in
Bandarban area, Marmas mostly got affected with diarrhea (32.1 %).
From total household members (N*=888) 378 people has affected with
water borne or skin diseases, where 344 were slum dwellers and 44
were Marma tribes.
Health service centers and their facilities
Respondents had been asked about the quality and availability of
health service facilities.
Sanitary napkin Cotton Clothe
Total 17.3% 3.5% 74.6%
Slum 16.5% 4.5% 77.5%
Marma 16.5% 4.5% 77.5%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
Used materials during menstruation (Who do use any method)
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Table 7: Descriptive analysis of Health service centers and their facilities (N*= 888)
Variables Total Slum Marma
n % n % n %
Visiting doctor for diseases: Diarrhoea
Cholera Typhoid Dengue
Chikungunya Skin Diseases Other
43
12 25 64
186 19 15
4.8
1.4 2.8 7.2
21.0 2.0 1.7
29
12 24 61
176 13 15
4.5
2.0 3.8 9.5
27.5 2.0 2.0
14
0 1 3
10 6 0
5.6
0.0 0.4 1.2
4.0 2.4 0.0
Availability of health service centers within one kilometer of home:
Yes No
241 19
92.7 7.3
196
4
98.0 2.0
45 15
75.0 25.0
Place of the health center: Same para/Moholla
Other area City area
233
12 15
89.6
4.6 5.8
199
1 0
99.5
0.5 0.0
34
11 15
56.7
18.3 25.0
Quality of health services: Very good Good Preventable
Poor
2 59
196
3
0.8 22.7 75.5
1.0
0 22
175
3
0.0 11.0 87.5
1.5
2 37 21
0
3.3 61.7 35.0
0.0
Whether have any
knowledge of respondents about important of safe WASH
system: Yes No
174 86
67.0 33.0
127 73
63.5 36.5
47 13
78.3 21.7
About 98% slum dwellers and about 75% Marma tribes replied that
they have health service centers in same area. About 87% slum
dwellers think that services of these health service centers are
‘preventable’. On the other hand 61.7% Marmas evaluate the services
of these health service centers as ‘good’.
Chapter - 5
Bivariate& Multivariable Analysis
Bivariate Analysis: Cross table and chi square test
Socio-Demographical Study
Table 1: Crosstab between age group and level education
No education Primary Secondary Tertiary
0-15
Slum 46.7% 30.3% 23% 0%
Marma 11% 51.5% 37.5% 0%
15-
40
Slum 63.4% 19% 17.6% 0%
Marma 46.3% 15.5% 33% 5.2%
40-
65
Slum 65.8% 14.2% 20% 0%
Marma 73% 16.5% 10.5% 0%
65+
Slum 100% 0% 0% 0%
Marma 90% 10% 0% 0%
Table 2: Percentage of Dengue by areas
Dengue P value
(.05)
no yes .000
Area Slum 90.3% 9.7%
Marma 98.8% 1.2%
Through the result of cross tabulation between Area of respondent and
percentage of Dengue patient we can see that 9.7% slum dwellers and
only 1.2%Marma tribes got affected with Dengue. P-value for both
results is .000 which defines that the relationship is significant.
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Figure 6: Percentage of Chikungunya patients by areas(N=260) (Slum=200, Marma=60)
Above figure gives us idea that from slum area about 35% people and from Marma area about14.3% people are affected with Chikungunya disease,
else haven’t affected.
Water Usage System
Figure 7: Percentage of Diarrhoea patient who purify drinking water by areas
Slum Marma
Chikungunia patient 35.0% 14.3%
0.0%
10.0%
20.0%
30.0%
40.0%
Percentage of Chikungunya patient
Yes No
Percentage of Diarrhea patientamong them who purify
drinking water3.4% 96.6%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Percentage of Diarrhoea patient who purify drinking water (Total)
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Respondent had been asked whether they do anything to purify their
drinking water, then some of them replied positively and some
negatively. Above table showing us that those who purify drinking
water their chances of getting affected by diarrhoea diseases is only
3.4% In slum area those who purify water, among them only 3.4%
people got affected with diarrhoea and Marmas who purify water
among them 100% people, which is all of them does not affected with
Diarrhoeal diseases.
Yes No
Percentage of Diarrhea Patientamong them who purify
drinking water3.4% 96.6%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Percentage of Diarrhoea patient who purify drinking water (Slum)
Yes No
Percentage of Diarrhea Patientamong them who purify
drinking water0.0% 100.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
120.0%
Percentage of Diarrhoea patient who purify drinking water (Marma)
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Sanitation Practice System
Table 3: Crosstab between disposal of stool & garbage and percentage of Dengue & Chikungunya patient.
Dispose of stool after defecation
Percentage of Dengue patient P-value (0.05)
Open place 6.0% .490
Nearby river/pond 13.0%
Percentage of Chikungunya patient
Open place 8.0% .009
Nearby river/pond 29.0%
Percentage of Chikungunya patient
Place of regular garbage disposal
Open place 8.3% .006
Nearby river/pond 29.4%
About 6% people got affected with Dengue who disposes their stool at open places and 13% people got affected who dispose their stool in nearby river
or pond. About 29% people got affected with Chikungunya who dispose stool after defecation in nearby river or pond.
Hygienic System
Table 4: Crosstab of Knowledge of respondents about Hygienic practice
Variables
Use of methods during menstruation
P-value
(0.05) Sanitary napkin Cotton
Clothe
Education level
No education 8.8% 2.2% 89.0%
.000 Primary level 31.4% 6.5% 62.1%
Secondary level 32.6% 5.8% 61.6%
Knowledge about the importance of hygienic
practice
Yes No
Percentage of Dengue patient
4.6% 24.4%
Percentage of Chikungunya patient
Yes 21.3%
No 29.0%
Knowledge about the importance of hygienic practice
Percentage of patient affected with any water
borne or skin diseases
Yes No
Yes 71.3% 28.7%
No 81.4% 18.6%
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Relationship between education level and use of methods during
menstruation has highly significance (.000). The people who have no
education, from them about 89% people use clothe 2% use cotton, and
8.8% use sanitary napkin. Crosstabs result has shown that the higher
their education level lesser the percentage of clothe user. Another
result has shown that about 71.3% people are affected with water
borne or skin diseases who have knowledge about the importance of
safe WASH system.
Table 5: Crosstab of awareness of respondents about hygienic practice.
Knowledge about the importance of safe drinking water
Stay clean Boil water Keepwater fresh
Yes 49.4% 12.6% 38.0%
Knowledge about the importance of safe sanitation practice Stay clean
Use soap after
defecation
Use fresh and modern
sanitary
Yes 60.0% 8.0% 32.0%
knowledge about the importance
of safe hygienic practice Stay clean Fresh environment
Take fresh and nutritious
food
Yes 66.0% 3.0% 31.0%
Above data can define about previous table result (table- 4). People
who have knowledge about fresh WASH system among them about
49% know that they have to stay clean in terms of safe drinking water,
only 12.6% know about the importance of boiling drinking water. Only
8% know about the importance of using soap after defecation and 32%
aware about fresh and modern sanitary and only 31% aware about the
importance of taking fresh and nutritious food.
Table 5.1: Crosstab of Awareness of respondents about Hygienic practice (Slum area).
Knowledge about the importance of safe drinking water
Stay clean Boil water Keep water fresh
Yes 55.1% 13.4% 31.5%
Knowledge about the importance of safe sanitation practice
Stay clean Use soap after
defecation
Use fresh and modern
sanitary
Yes 57.5% 10.2% 32.3%
knowledge about the importance
of safe hygienic practice Stay clean Fresh environment Take fresh and nutritious
food
Yes 68.5% 3.9% 27.6%
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Table 5.2: Crosstab of Awareness of respondents about Hygienic practice (Marma area).
Knowledge about the importance
of safe drinking water
Stay clean Boil water Keep water fresh
Yes 34% 10.6% 55.4%
Knowledge about the importance
of safe sanitation practice Stay clean
Use soap after
defecation
Use fresh and modern
sanitary
Yes 66% 2.1% 31.9%
knowledge about the importance
of safe hygienic practice Stay clean Fresh environment
Take fresh and nutritious
food
Yes 44.7% 15% 40.3%
About 68.5% slum dwellers and 44.7% Marmas have knowledge that
they should stay clean regarding safe hygienic practice. 10.2% slum
dwellers and only 2.1% Marma tribe have knowledge about the
importance of wash hand with soap after defecation.
Health Service Facilities
Table 6: Crosstab between type of treatment for different diseases and their costs
Health
centre
Doctor Nurse/
paramedics
Pharmacy Kabiraj Self-
medication
P-value
(0.05)
Diarrhoea 0-200 13.4% 0.0% 0.0% 73.3% 0.0% 13.3%
.001
300-500 33.3% 0.0% 0.0% 66.7% 0.0% 0.0%
500-1000 60.0% 0.0% 40.0% 0.0% 0.0% 0.0%
1000-5000 60.0% 0.0% 0.0% 40.0% 0.0% 0.0%
5000+ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Cholera 0-200 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
300-500 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
500-1000 100% 0.0% 0.0% 0.0% 0.0% 0.0%
1000-5000 100% 0.0% 0.0% 0.0% 0.0% 0.0%
5000+ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Typhoid 0-200 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
.618
300-500 100% 0.0% 0.0% 0.0% 0.0% 0.0%
500-1000 92.3% 7.7% 0.0% 0.0% 0.0% 0.0%
1000-5000 100% 0.0% 0.0% 0.0% 0.0% 0.0%
5000+ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Dengue 0-200 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
.000
300-500 23.0% 15.5% 0.0% 61.5% 0.0% 0.0%
500-1000 72.7% 27.3% 0.0% 0.0% 0.0% 0.0%
1000-5000 97.3% 0.0% 0.0% 2.7% 0.0% 0.0%
5000+ 100% 0.0% 0.0% 0.0% 0.0% 0.0%
Chikungunya 0-200 0.0% 1.3% 0.0% 94.7% 0.7% 3.3%
.000
300-500 13.6% 9.0% 0.0% 77.4% 0.0% 0.0%
500-1000 33.3% 0.0% 0.0% 66.7% 0.0% 0.0%
1000-5000 0.0% 75.0% 0.0% 0.0% 0.0% 25.0%
5000+ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
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Skin diseases 0-200 0.0% 0.0% 0.0% 33.3% 66.7% 0.0%
.000
300-500 0.0% 100% 0.0% 0.0% 0.0% 0.0%
500-1000 90.0% 0.0% 0.0% 0.0% 10.0% 0.0%
1000-5000 100% 0.0% 0.0% 0.0% 0.0% 0.0%
5000+ 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Through the above data it has been seen that relationship between
cost of the diseases and type of treatment has significance. People
who suffer with Diarrhoea disease from them about 73% people has to
pay 0-200 taka by taking treatment from pharmacy and 60% spent
500-1000 through health centers. 94.7% Chikungunya patient spent 0-
200 taka by taking treatment from pharmacy and 77.3% Chikungunya
patient spent 300-500 taka by taking treatment pharmacy.
Multivariable Binary Logistic Regression Analysis
Multiple binary logistic regressions have been run for this study to see
the actual relation between binary or dichotomous dependent variable
and multiple categorical or continuous independent variables. This
analysis is the predictive analysis.
Dependent variable: Percentage of affected people with different
kinds of water borne or skin diseases.
Socio-Demographical study
Table 1: Logistic regression analysis between patient of affected diseases and socio-demographical terms.
B S.E. Wald df Sig. Exp(B)
95% C.I.for EXP(B)
Lower Upper
Sex -.508 .313 2.646 1 .104 .601 .326 1.110
Occupation with
higher category
-.124 1.172 .011 1 .916 .883 .089 8.790
Above table showing us that from the respondent’s area, male group of
population are less likely to have infectious diseases than female
group of people. Male has about 40% lesser chance to get affected.
Occupation has been categorized in terms of higher to lower category.
Those who do high ranking job or those are army or student or teacher
they have 12% less chance to get affected with diseases than other
group of people, like- farmer, jum farming, rickshaw puller, maid, and
so on.
Water usage system
Table 2: Logistic regression analysis between patient of affected diseases and their water usage system.
B S.E. Wald df Sig. Exp(B)
95% C.I.for EXP(B)
Lower Upper
Whether make
drinking water
safe
-.827 .416 3.949 1 .047 .437 .193 .989
Main source of
drinking water
-1.093 .463 5.573 1 .018 .335 .135 .831
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We can see that those purify the drinking water they have 56% less
chance to get affected with infectious or water borne diseases than
those who do not purify. Main source of drinking water has been
categorized into two groups, which are piped/supply water and natural
source of water, like- river, pond, lake, and so on. Through the logistic
regression analysis it can be seen that people who use piped water
they have 66.5% lees chance to get affected than natural source user.
Both are the relationship showing significance (.047 and .018).
Sanitation Practice
Table 3: Logistic regression analysis between patient of affected diseases and their sanitation practice system.
B S.E. Wald df Sig. Exp(B)
95% C.I.for EXP(B)
Lower Upper
Way of
washing hand
after defecation
-1.791 .402 19.871 1 .000 .167 .076 .367
Logistic regression analysis can clearly show that way of wash hand
after defecation has deep significant (.000) relationship with the
diseases. Those who wash hand with soap after defecation they have
83% less chance to have infectious diseases
.
Hygienic practice system
Table 4: Logistic regression analysis between patient of affected diseases and Hygienic Practice.
B S.E. Wald df Sig. Exp(B)
95% C.I.for EXP(B)
Lower Upper
No of household
who use one
sanitary
-.126 .073 2.944 1 .086 .882 .764 1.018
Way of washing
hand after
defecation
-1.512 .617 6.007 1 .014 .220 .066 .739
Above analysis can be define in a way that the lesser the number of
household who use one sanitary the lesser their chance to get affected
with infectious diseases; At least 12% less chance to get affected with
infectious diseases. Here also we can see about the significant (.086 &
.014) relationship between way of washing hand after defecation and
diseases.
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WASH System
Table 5: Logistic regression analysis between patient of affected diseases and WASH system.
B S.E. Wald df Sig. Exp(B)
95% C.I.for EXP(B)
Lower Upper
Number of
household who
use one sanitary
-.100 .086 1.332 1 .248 .905 .764 1.072
Way of washing
had after
defecation
-1.884 .906 4.322 1 .038 .152 .026 .898
Make drinking
water purify or not
-.513 .677 .574 1 .449 .599 .159 2.257
Wash food before
cooking
-2.388 1.132 4.449 1 .035 .092 .010 .845
Sex of
respondent
-.740 .465 2.529 1 .112 .477 .192 1.188
Above analytical table can define the hypothetical chance of getting
affected with diseases in terms of different independent variables. Male
group of people have 52% less chance to get affected. People who
follow safe WASH system, they are likely to have less chance to get
affected with diseases. Like, who wash food before cooking they have
91% less chance, then who purify the drinking water they have at least
40% less chance. Though some of the relationship between variables
are not showing significance but their odds ratio are meeting the target
of predicted overview which can consider as important fact of this
paper.
Chapter - 6
Discussion
Bangladesh has made significant improvement in various
sectors particularly in socioeconomic and health sectors
since its independence in 1971 (Khan et al, 2011). These
improvements are clearly revealed at the aggregated level
by various indicators like declining poverty, infant and child
mortality, increasing life expectancy, water, sanitation and
healthcare development throughout the country. However,
group-specific analyses indicate that such improvement
varies remarkably across geographical areas and societies.
Still a large number of groups stay in socioeconomically and
geographically challenging situations. Urban slum dwellers
and Marma tribe communities are two vulnerable groups
who are socioeconomically and geographically
disadvantaged and are at higher risk of suffering from
infectious diseases due to poor socioeconomic, lifestyles
and environmental conditions including limited facilities,
knowledge, awareness and practice for safe WASH system.
This study has been conducted to perform comparative
analysis of WASH system between Marma tribe in
Bandarban district and urban slum dwellers in Dhaka. The
major aims of this research were to report the prevalence of
safe WASH practices by two groups and how their WASH
practices are associated with infectious and water borne
diseases. Before starting data collection, the sample size for
each area has been determined purposefully focusing on
accessibility to the study area, cost and time. Then some
particular villages (locally called paras) of Marma tribes and
some slums in Dhaka have been selected for data collection.
A sampling frame of households for each village or slum has
been prepared and then selected households based on
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systematic sampling have been chosen for collecting data
using pre-tested questionnaire. The main respondent of the
questionnaire was normally the head of the household. After
collecting data, SPSS software and Microsoft office Excel
were used to analyse them. Through this study I have found
out that both areas are relatively vulnerable in terms of their
hygienic practice system. WHO report has reported about
sex ratio of Bangladesh, and it says that this country has
100.3 male against 100 female. In this study also we have
seen that, from slum area there are 64% male and 34%
female. As main respondent of this study was head of
household, so, this percentage has been found on the basis
of that. According to Marma’s matriarchal culture, I have
found 46.7% male and 53% female is head of the
household.
According to the findings of my research, both urban slum
dwellers and Marma tribes minimally practice safe WASH
system in their daily lives. Their water usage system,
sanitation practice and all other hygienic practices often do
not meet safe WASH system. Their living arrangement and
income indicated poor conditions. For example, in a tiny little
room many people are staying together. They are also
sharing toilet which is mostly under-developed and
unhygienic. It has been found that in slum area one toiletwas
used by 15 (on an average) households. From these
households of slum area it has been found out that a large
portion of people are mostly uneducated and having limited
knowledge about safe WASH practice due to their poor
socio-economic conditions. It has also been found that they
are very versatile in terms of their occupation. On the basis
of geographical condition and socio-cultural issues they do
different jobs. For example, Marmas do jum (Any type of
farming which used to be done at hilly area not on low land
area) farming as it is one of the main source of their
economy which cannot be seen in slum area of the city. Jum
farming can only be done in hilly areas but not in the city like
Dhaka (without hilly part). Many slum dwellers are garment
worker as urban areas are mostly industrial based.
Due to geographical condition Marma community generally
spend more money per month to maintain their livelihoods
than slum dwellers. Most of their daily essential products
including some food items cannot be produced or easily get
in hilly areas. So, they need to travel far to collect them,
which results- extra transport cost and time. My study has
shown that comparatively slum area people are more
educated than Marma tribe, because I have found out that
‘No education’ rate of head of the respondent’s at slum area
is about 57% and at Marma community is about 68%. It has
been found out that literacy rate has been increased from
2007 to 2016 which is 46.66% to 72.76% (Unesco Institute
for Statistics report, 2016). This rate is also true for this study
also, because through data I have found out that though
most of the elderly Marma people are illiterate but now their
children are getting educated and their literacy rate is also
getting higher. They have to spend a large portion of their
income for their children’s education due to lack of facilities
as compared to slum dwellers. Although education is
important factor to increase knowledge, awareness and
practices of the safe WASH system, the education rate is not
satisfactory in Marma community and should be improved. It
has been also found that most of the household works are
done by female members though head of the household is
male. Females are less aware about their health conditions
or hygiene that promotes their health. For instance, during
their menstruation periods most of them use unhygienic
clothes. Moreover, they cannot drink enough water and
cannot get enough chance to become fresh due to their busy
family issues.
There is a common proverb in our societies called “Water is
life”. This statement clearly signifies the huge importance of
safe water. If someone sufficiently drinks safe water, he/she
can protect himself/herself from dehydration. It can also
reduce the chances of many diseases like water-borne and
skin diseases. In contrast, if someone drinks unsafe dirty
water, he/she can experience many diseases like diarrhoea,
cholera, eczema, and so on..Water is used for other
purposes such as for washing utensils and clothes, cleaning
hands and mouth, and so on. Irrespective of the purposes of
water uses, water has to be safe, fresh and purified.
Everybody should take some actions to make the drinking
water purified before drinking. Other water-related actions of
daily lives (such as washing hands and utensils) should be
implemented with fresh and safe water. Unfortunately,
available water in both areas are limited and suffer from poor
quality. However, this problem is more severe in Marma
community. Most of Marmap eople drink water from natural
sources like rivers, ponds or tube-wells, and lakes which are
unhygienic and contaminated. They also perform various
activities such as cleaning clothes, utensil or other works
using water from ponds or lakes..It is also noticed that they
disposed their used/dirty water to the nearby rivers or ponds.
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As a result, the water becomes more contaminated and
increases the chance of water-related diseases. Since most
all the Marma people do not boil or do anything to make
drinking water safe, they generally suffer more from
diarrhoeal diseases than slum dwellers in Dhaka. Practice of
drinking water purification is very rare in Marma area, which
is only 3% but about 97% slum dwellers purify water. It has
been found out that in slum area those who purify water
among them only 3.4% have suffered with diarrhoea and in
Marma area those who purify water among them no one has
suffered with diarrhoea. Rate of diarrhoea diseases is higher
in Marma area than slum area and it has caused due to their
practice of unpurified water drink. Around 45000 children die
due to diarrhoea disease every year and contaminated
drinking water is one of the main causes of this disease
(WHO report, 2018).WHO has found out that this disease is
mainly a symptom of infection that caused by contaminated
water. This rate should reduce as soon as possible through
safe WASH practice.
Like water, the global sanitation problem is huge. The MDG
sanitation target, to halve the proportion of people lacking
access to improved sanitation by 2015, is seriously off-
tracked. About 2.5 billion people had limited access to basic
sanitation in 2015 (Eid, U. (2015, January 21). The overall
sanitary system in both study areas is under developed and
requires urgent attention. Most of the survey populations use
slap latrine which is generally open. When the respondent
was asked to report about places for discharging their stools
and other garbage, they replied that mostly it goes into the
near riverside areas. Some people have even said that they
use these contaminated water to take bath and wash their
clothes and utensils. Briefly, the overall sanitation system in
the study areas is highly unsafe and unhygienic for the
population. Sharing toilet with other households is very
common practice mostly in slum area. Study has revealed
that, 97% slum dwellers and 36.7% Marma tribes share toilet
with other households. Around 40% of all latrinesin
Bangladesh has classified as unimproved (The World Bank
report (2016). From my study it has shown that, both slum
and Marma area’s people do not use modern toilet as after
study it has shown that 97% slum dwellers use sealed/slap
latrine and 48% Marma tribes use hanging latrine. Both
systems are not hygienic at all, because sewerage system of
these types of latrine is not well developed. After research it
has found out that only 18% of the city got improved
sanitation system (The World Bank, 2016). Comparatively
Marma population use personal washrooms more, than
share it. Mostly they use sealed or slap latrine and another
second large amount is open latrine which is used by
Marmas. Disposal of stool or other garbage’s done mostly in
nearby river or pond by slum dwellers, but Marmas mostly
dispose it in open place. Practice of dispose garbage’s or
child’s stool in dustbin is very much rare.
Slum area people have only one wash room for many
households. They do not clean those washrooms at all and
even those are not modern. Sanitation makes a positive
contribution in family literacy. According to a UNICEF study,
for every 10% increase in female literacy, a country’s
economy can grow by 0.3%. Thus, sanitation contributes to
social and economic development of the society. Improved
sanitation also helps the environment. Due to lacking of
proper education and knowledge regarding developed
sanitation system, many slum dwellers and Marma tribe has
to suffer from many infectious diseases. They do not clean
the latrine properly at all which pollutes environment as well
as put effect on health condition of people. Marma tribes are
not aware about fresh environment and this has been proved
when I have found out about the rate that says- about 76.7%
tribals dispose child’s stool at open place. Germs of those
stools pollute the air and increase risk of infectious diseases
like – diarrhoea and skin diseases. World Bank Report
(2016) also has suggested eliminating the practice of open
defecation to reduce the rate of Diarrhoeal disease.
Everyone should have knowledge regarding safe WASH
practice as it is very important for better life. Practicing
hygienic WASH system really need for everybody. From the
study it has been shown that almost everybody wash hand
after defecation but everybody do not use soap for that.
From study data analysis we can see that only 10.2% slum
dwellers and only 2.1% Marma tribes have awareness about
the importance of using soap after defecation, which rate
obviously should increase. Even most of them wash hand
before having their meal but they do not use soap; and this
view is same in both areas. While asking them about this, it
has been seen that they even does not think this as wrong
practice. And to me that’s the main reason of their bad
health condition, that they mainly do not have awareness.
Female member of both Marma tribe and urban slum
dwellers use clothe mostly during their menstruation which
doesn’t even get dried up in sunny weather.
In our daily life style we tend to do lots of things which are
not hygienic and also not good for our health. We have fast
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food mostly which really doesn’t good and known as junk
food. Whenever we stay outside of home we eat food
without washing our hand and even without washing the
fruits we just directly eat. Even if we are educated person
and know about the importance of hygienic system, we do
these things. Urban slum dwellers are mostly uneducated
and they do not have that much knowledge about the
importance of hygienic practice. The place where they live
those are not clean and fresh at al. As they are not using
soap or any kind of hand sanitizer, the germ exists in their
body and it get into their stomach with food.
Unhygienic WASH practices can affect people with many
types of diseases. These diseases are mostly infectious
which contain virus even. Unclean water usage can cause
water borne diseases and skin diseases also. Throughout
the study it has been found that mostly urban slum dwellers
got affected with diseases than Marma tribe.
Diarrhoea is a symptom of instinctual tract infection which
results due to bacteria. Bacterial disease mostly produces
and spread by water. Drinking unsafe water and use unclean
water can cause infectious disease in human being’s body.
Unhygienic, damn, unclean environment can cause
production of mosquitoes. Mosquitoes mostly like to stay in
dark areas, in open water pots, and in sewerage, and so on.
Slum dwellers mostly stay in these types of places. Their
house, sewerage system, and drinking water source
everything situated in same area. Their sewerage system is
not developed at all; in fact their garbage cannot pass easily.
So, those get overflowed. These all things caused birth of
infectious mosquitoes. One emerging diseases –
‘Chikungunya’ last year spread significantly in urban areas.
Slum dwellers have also got affected with this disease about
which I have come to know through analysis of my study.
Slum area people stays in very congested, dark, muddy and
unhealthy situation. In one room about 6-7 person stays.
Their environment of living place is not clean at all. Most of
them stay near drainage system. Mosquitoes always roam
around there. Last year one emerging diseases which
named Chikungunya has affected many people. Throughout
the study it has been found out that Chikungunya is a
leading disease among the selected areas. Last year most of
the people got affected by Chikungunya which results due to
a kind of infectious mosquito. Around 9 lack. (5% of total
population of Dhaka city) people got affected with this
infectious disease (ProthomAlo, 18th July, 2018). Throughout
this study I have also found that the higher percentage of
respondent got affected with Chikungunya. They also got
affected by other diseases also, like- Dengue, Diarrhoea,
skin diseases, and others.
This result does not meet the national level result. In national
level most leading cause is Diarrhoea. But Diarrhoea is very
common diseases now and now a day everybody knows
about it and they know a minimum level of primary treatment
for it. But in this paper people of selected areas has informed
that they suffered more with Chikungunya in last one year. In
terms of national level it can differ. Cholera or Diarrhoea
these are age old disease. Although its incidence is declining
and new diseases such as Chikungunya or Dengue are
emerging. Moreover this study has been conducted with
selective sample which cannot represent whole nation.
Because in national level way of practicing WASH system is
different in terms of their knowledge, their geographical
condition, their socio-economic condition, and so on.
Diarrhoea is observed nationwide while Chikungunya is
mostly centered in urban areas. Basically what is true for the
whole is not true for selective areas or persons. This is call
ecological fallacy.
These things happen because of their lacking of proper
knowledge and especially lacking of their awareness about
being safe and clean. Through the statistical analysis it has
been showed that most of the infectious disease affected
people have knowledge about cleanness but they do not
know the actual way of being clean. There are four steps
theory in medical sociological terms.
Those are-
1. People who do not have knowledge and
awareness.
2. People who do have knowledge but do not have
awareness.
3. People who do not have knowledge but have
awareness of being healthy
4. People who have both knowledge and awareness.
So, in my study respondent’s condition is second one, which
says that they have knowledge but they are not aware about
their safety.
Now technology is being developed and it is making people’s
life easier. Most of the respondents reply positively about
health service centers. Most of them replied that services of
health service centers are at least preventable and to them
that’s the main fact. They are aware about their health issue
and that’s why they go and ask for treatment in hospitals or
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to doctor or to pharmacy for any serious diseases like-
Diarrhoea, Chikungunya or Dengue. Most of them know
about the importance of safe WASH system through different
types of source, like- health service provider, community
clinic, advertisement, TV show or books, and mainly from
neighborhoods.
Though most of them have knowledge about safe WASH
system but most of them are not aware about the procedure
of safe WASH practice. Most of them know that they have to
stay clean but only few practices and know about importance
of boil drinking water, wash hand after defecation and even
fresh environment.
Health sector facilities are getting developed day by day. In
most of the para/moholla a minimum level of services are
being provided. In Bandarban district, most of the
respondents informed that there were health service centers
in same para of the respondent’s house or in other para.
People agreed to go to those places for seeking treatment.
But mostly they visit doctors and take medicine. On the other
side they do own medication also. Mostly they do this
because expense of treatment in health service are more
than private doctor’s treatment or own medication. Urban
slum dwellers not even visit any health service centers if
they do not feel that much urgent.
In my study people of both areas are socially as well as
economically challenged. Their lifestyle is like ‘hand to
mouth’. So, their main focus is just how to arrange food for
themselves and their family. It is totally a rare practice for
them to think or aware about the safety of their health
condition in terms of their lifestyle. They are mainly fond of
some basic needs like- food, clothe and shelter. It won’t
make any difference in their life style situation if they
themselves do not grow awareness about safe WASH
practice system. We need to make them understand that, it
is one of the main issues which they obviously need to know
for their good health condition. If they can feel that these
regular WASH practices are interrelated with their well-
being, then they would understand the importance. It is
actually a combination of understanding and awareness and
both need to be build up in a proper way.
After over viewing the whole study we can say that, Marma
tribes are more vulnerable than slum dwellers in terms of ‘No
education rate’, ‘Safe drinking water’, ‘Sanitation practice
system’, and also their awareness regarding safe WASH
practice. Compared to national level statistics it can say that
both areas are vulnerable. In Marma area we have found
that due to unsafe drinking water and unhygienic sanitation
system, they have to suffer with Diarrhoea more than slum
dwellers. On the other hand till now slum dwellers have
suffered with Dengue and Chikungunya more, than Marma
tribes because of their unhygienic living condition. We can
say that, it does not matter whether they are staying in urban
area or rural eco-friendly area; rather it is a matter of
unprivileged community who are vulnerable in every sector.
Basically we can say that it does not matter that two study
areas are belongs from two different areas; rather it’s a
matter of their socio-economic condition, that makes their life
vulnerable.
Limitations:
While doing any kind of study it is common to face some
limitations which I have also faced while I was working on
this paper. As I was doing Intern at that moment so, time
was an important issue for me. It was so difficult for me to
manage time to go to study area and collect data. Same
reason has not let me completed the paper within due date.
Another challenge was lacking of participatory and active
response of every respondent. Usually I went to collect data
at day time when most of the households were at outside for
their daily work. So, I had to wait for long or sometimes left
that household without taking interview. I have also faced
problem with respondent’s biased answer. Some of them
have followed other’s answer and some have tried to choose
the better option. Limited financial support was one of the
main causes in this thesis work. As a student, it was really
difficult for me to arrange financial support for collecting data
and other expenses.
Chapter - 7
Conclusion and Recommendation
Conclusion
Knowledge about safe water, sanitation and hygienic system
is limited among Marma tribe and urban slum dwellers. Most
of them know that everybody should practice safe WASH
system but they don’t know the ways to do. This situation is
clearly revealed when they said that they do not boil or do
anything to make their drinking water safe. Even their
sanitation system is not well developed though they were
complaining about the sewerage system. Many female still
use clothes while having menstruation and these materials
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get dried up in dark and unclean places. In our country
tribals are known as minority group. So, in terms of other
group of people their condition and situation is way much
miserable in terms of their education, career, cultural and
language issue. On the other hand slum dwellers were
already led a traumatic situation from their origin. They were
not happy at their origin and that’s why they have moved to
other place but throughout the study it seems that they are
not even in a good condition at their destination which known
as urban slum. To get a better life they come to city area, but
it is their bad luck that they cannot access proper information
and gather proper knowledge about the current situation of
job market or about living accommodation in city area.
Because of their lacking of knowledge they have to suffer a
lot. Here they cannot get a developed housing system, like-
proper sanitation, fresh drinking water, hygienic room and
toilet, and so on. We only give our focus on large city area,
but we should look after on other small regions also. We
need to do lots of developmental work in hilly areas to make
tribal’s life more smooth and productive and also we need to
check why numbers of slum dwellers are increasing day by
day. Government should take some initiative so that they
can get a way to stay in their own region. If they can get to
do work for their bread and butter then they wouldn’t come to
one particular city area. It could reduce their unhygienic
practice of WASH system also. They are practicing very
unhygienic sanitation and unsafe usage of water system;
although they replied that they know about the importance of
safe drinking water and other hygienic practices. The
findings of this research clearly suggest that their awareness
regarding safe WASH system should be immediately
improved by relevant stakeholders. Economical help and
social awareness can be a great source of improvement.
Recommendation
It is not possible to develop any group of people within a
short period of time. Every nation need some time to achieve
their target. But to achieve anything we have to take some
basic initiatives.
On the basis of my review of literature and practical
experiences, I recommend following strategies to improve
the overall situation of WASH system among the study
populations.
i. Provide health education about safe WASH
by the concerned authorities working in the
study areas.
ii. Ensure arsenic and contaminated free
drinking water for all by Governmental
authoritative member.
iii. Allocate special funds for improving water,
sanitation and drainage system in the study
areas.
iv. Need to ensure free monthly health care
service for Adolescents and reproductive
women in terms of sanitary napkin and
sanitation related other hygiene kit.
v. To ensure sustainable and safe sanitation
with proper implementation of the
management services in every public spaces
for – women, children and handicaps.
vi. Create social awareness for improving water,
sanitation and other environmental services
in the study areas.
vii. Further epidemiological studies based on
sound methodologies and study designs
should be conducted to gain further
knowledge about risk factors of their common
health problems.
Acknowledgement
It is a blessing of mine that I have been able to work on the
said topic with two most challenging area. First of all I would
like to thank to almighty Allah and of course my mom and
dad for my achievement. Without my mom and dad’s support
I couldn’t came forward and do anything in my life. They
have supported me in every single moment while doing this
thesis. They have given a very friendly support while
collecting data in Marma area.
I would like to thank Dr. Rafiqul Huda Chaudhury (Honorary
Professor, Coordinator and Adviser – Graduate Program in
Population, Reproductive Health, Gender& Development) for
his unending and full support. He has played a father like
role in my life regarding my study and career development.
Without his support it wouldn’t be possible for me to study in
this subject smoothly. At first he is the person who has
guided me to develop the idea and whole content of this
paper. I got his great support throughout my whole thesis
work.
Dr. Md. Mobarak Hossain Khan, Professor & Chairperson-
Department of Social Relations is such a good hearted
person. My learning from Mobarak sir is unending. He has
supported, guided and helped me from the start to end of
this thesis work. Without his help it wouldn’t be possible for
me to complete this thesis within this short period of time. He
has developed my idea regarding SPSS software also.
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Study Area:
Urban Slum
Marma Community
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